SECTION 1: FATIGUE

Fatigue is one of the most common symptoms of MS. The term is generally used to refer to a "lassitude" characterized by an overwhelming sleepiness that often comes on suddenly. A number of strategies and medications may be helpful.

NON-PHARMACOLOGIC MANAGEMENT

Energy conservation

You may be able to see a pattern to your fatigue. For example, many people find that their fatigue is at its worst in the afternoon. You can learn to plan your activities to take advantage of those times when you tend to have the most energy, and to pace your activities to allow for rest periods. An occupational therapist can help you conserve your energy by balancing activity and rest, so that you are able to enjoy the things you most want to do.

Cooling

Because many people with MS are heat-sensitive and find that their fatigue is increased in hot weather or in warm indoor environments, a variety of cooling techniques have been found useful. These include swimming in cool water, taking cool drinks on warm days, using air conditioning, and using cooling apparel or other accessories. MSAA has a Cooling Equipment Distribution Program, which provides various types of apparel (such as vests, neck wraps, and wristbands) to individuals who qualify. These types of products may also be purchased through various retailers.

Manage Secondary Causes

Fatigue can result from a variety of metabolic and hormonal conditions, sleep deprivation, depression and anxiety, and a variety of medications. It is important that your health provider address these problems with a comprehensive checkup if you are experiencing fatigue. Stress management techniques such as meditation may be helpful in managing fatigue. Because de-conditioning, contributes to fatigue, exercise - especially aerobic exercise in moderation - may also be helpful in decreasing fatigue.

PHARMACOLOGIC MANAGEMENT

A number of drugs have been used effectively to manage fatigue. Many of them were first developed to treat other disorders such as alertness or depression.

Provigil®(modafinil)

This is an oral medication whose usual dose is 100 to 200 mg daily, although dosages up to 400 mg are sometimes needed. It should be taken early in the day to minimize sleep disturbances. This drug promotes wakefulness, and was originally developed to treat narcolepsy, a neurologic condition associated with uncontrollable daytime sleepiness.

Reports of the drug's effectiveness in MS have been mixed. Its use in MS was first based on a 2002 study from Ohio State University showing improvement in 65 patients with a dose of 200 mg per day. A more recent randomized, placebo-controlled, double-blind study in Germany was performed in 121 patients who had a high baseline score on the Fatigue Severity Scale (FSS) and an Expanded Disability Status Scale (EDSS) score of less than 7. Initial evaluation of the data showed significant improvement in fatigue, cognitive impairment, and walking. However, a study comparing modafinil to antidepressant therapy in 64 patients found that antidepressant treatment was more effective as measured by a number of test criteria.

Side effects most commonly seen are headaches, insomnia, nausea, and constipation.

Amantadine

This generic medication was previously available as Symmetrel®. This is an oral medication whose usual dose is 100 to 200 mg daily. The drug should be taken early in the day to minimize sleep disturbances.

Amantadine is an antiviral medication used to prevent or treat influenza; it has also been used in Parkinson 's disease. Its mechanism for relieving fatigue in some individuals with MS is unknown, although it may increase levels of the neurotransmitter dopamine in the brain.

Side effects include rashes, dizziness or lightheadedness, insomnia, nausea, and constipation.

Ritalin®(methylphenidate)

This is an oral medication whose usual dose is 10 to 60 mg daily, usually taken 30 to 45 minutes before eating - or as your physician directs. Because it may cause difficulty sleeping, it is recommended that you take your last dose before 6:00 pm.

Methylphenidate was originally developed as a treatment for attention deficit disorder, and has also been used to manage narcolepsy.

A Phase I trial in 2003-2005 enrolled 80 patients with either RRMS or SPMS. It evaluated the effect of methylphenidate on cognition, not fatigue, but the link between the two supports its use for fatigue.

Side effects include nausea, dizziness, insomnia, severe or persistent headache, high blood pressure, and tachycardia (rapid heart rate); it should not be taken by individuals with serious heart problems.

Dexedrine®(dextroamphetamine)

This is an oral medication whose usual dose is 5 to 40 mg daily. This is a stimulant that has been used to improve wakefulness, boost energy, and decrease fatigue and appetite.

Side effects are similar to Ritalin®and include nausea, dizziness, insomnia, constipation, high blood pressure, and rapid heart rate.

Cylert®(pemoline)

Pemoline was withdrawn from the United States' market in 2005 due to rare but severe liver damage, resulting in death or liver transplant.

SSRIs are antidepressants, and are discussed in the section on Depression (page 24); managing the effects of depression may also alleviate symptoms of fatigue. These medications may need to be taken for several weeks before seeing an effect.

Caffeine

Caffeine taken as coffee, tea, or caffeinated soda, in moderation, can be helpful in managing fatigue. Individuals should speak with their doctor about their intake of these beverages, to be sure they are not exceeding levels of caffeine or sugar that are appropriate for them.